Provider Demographics
NPI:1922783869
Name:KIDD, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:KIDD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KUTZTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19530-1517
Mailing Address - Country:US
Mailing Address - Phone:484-258-4372
Mailing Address - Fax:
Practice Address - Street 1:420 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-2143
Practice Address - Country:US
Practice Address - Phone:484-628-7115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN664312364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology